Back Pain: A Potential Solution

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Back pain is a leading cause of work-loss days according to the Georgetown University Heath Policy Institute; that’s true in just about every high-income country. Finding a solution to reduce back pain occurrence not only reduces lost wages but also improves the quality of life of the individual.

Researchers in Australia wanted to find out whether a walking and educational program would reduce the recurrence of lower back pain resulting in medical treatment. They selected only patients who had lower back pain of undetermined origin; 701 patients were randomly assigned to the control group and experimental group. Both groups received the educational program. The experimental groups also received coaching on a walking program that they were to perform on their own. The goal was to walk 30 minutes per day, five days per week, but the program was adjusted to accommodate individual needs depending on initial fitness levels.

The results were interesting but not unexpected, in my opinion: those subjects in the walking group were 28% less likely to have a reoccurrence. Even better, the time to the next lower back pain event was about twice as long in the walking group, a median of 208 days versus 112 days in the control group. The researchers also found that the quality-of-life index they used was better in the walkers and that the walking program was cost effective compared to conventional treatment.

Lower back pain is something most of us experience at some point in time; wouldn’t it be great to go more than 200 days until your next episode? While some can be issues with nerves and vertebrae, at least some have no real cause other than weakness and tightness in muscles. With some basic core exercises and walking most days of the week, the solution just might be found on the sidewalk or pavement right outside your front door. Just make sure you get professional guidance before you start.

What are you prepared to do today?

        Dr. Chet

References:
1. https://hpi.georgetown.edu/backpain/
2. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(24)00755-4.pdf

Your Breath and Your Dental Health

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When I speak at events, I often answer questions afterward. To maintain some confidentiality, I often ask people to get close so it remains private. When you’re that close to people, you get a really good sense of the odor of their breath. People worry about garlic and onions but to me, those are normal. What shocks me is the odor of gum disease—I can’t believe people can’t smell it. Based on an article Paula sent to me, I understand it now.

The current name for it is smell blindness. Based on interviews with nose and throat specialists, it all has to do with saturating the nerve cells that detect odor, called olfactory cells, with the molecules from that odor. The nerve cells become so used to that stimulus, a person can’t smell that odor anymore. It’s kind of sad when you can’t smell your expensive perfume anymore, but it’s not a big problem. You probably don’t notice how your house smells until you walk back inside after being gone for a while. But when you carry the source of the smell around with you in your mouth all the time, it’s a huge problem and hard to solve.

I don’t get worried about adapting to many smells. If you like cats, there’s going to be a litter box odor you may not notice any more. Same may be true of the perfumed shampoo or conditioner you use every day. But the odor associated with gum disease means that there’s infection, and that’s problematic. Not only can it destroy your gums and loosen your teeth, the bacteria can get into your blood stream and impact your heart.

Not only is it bad for your health, it’s not good for your social life or professional prospects. And to look at it from another perspective, if you have a business where your employees get up close to people—checking their vision or cutting their hair, for instance—it’s a smart move to offer dental care. And it’s the right thing to do.

The author suggested that in a quiet moment, you ask someone you really trust to smell your breath. Even if you breathe into your cupped hands held in front of your nose, you may not be able to smell it. Better to ask a friend or loved one to do it to get an impartial opinion. If it smells like infection, see a dentist for a professional analysis. This one is too easy, and potentially too deadly, to ignore. Whether you have bad breath or not, everyone should be flossing every day and brushing after meals.

For more info on treatment for periodontal disease, go to the Store at drchet.com and check out The Bottom Line on Periodontal Disease; Insiders get a free copy of any Bottom Line.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.washingtonpost.com/wellness/2024/08/02/smell-bad-breath/

Long COVID and Possible Solutions

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I had a talk with someone who had a question about a skin condition, something that’s been a minor issue but suddenly got much worse. I happened to mention that sometimes when you deal with the flu or COVID, your immune system is weakened and it can impact other conditions; people report their symptoms began to get worse after a bout of COVID, almost to the day after recovering. Cause and effect? No way to know for sure. But long COVID is a reality; long COVID is a smorgasbord of illnesses that have been somehow triggered by COVID.

Coincidentally, an article was published on the development of treatments for long COVID. While there isn’t complete agreement exactly why it happens to some but not all those who’ve had COVID, physicians and scientists are looking at combinations of medications and supplements for possible solutions. While the article focused on using the antiviral Paxlovid, I was interested in the nutrient approach—specifically, the nutrients that focus on helping the mitochondria. Whatever else may be going on in long COVID, fatigue seems to be the worst side effect of the long COVID symptoms. That has to include an impact on the mitochondria regardless of whether it’s neurological or hormonal or even genetic in nature.

While other supplements were discussed, my experience is with N-acetyl cysteine and the amino acid glycine. Research has shown that when taken together, they help with repair and recycling of mitochondria. The typical amounts are about 600 mg of each per day; I’ve taken it regularly for a few years and I’ve noticed a difference in energy levels. Talk with your physician if you have long COVID or just have fatigue. There are also meds being tested for long COVID. The rest you know: eat less, eat better, move more.

What are you prepared to do today?

        Dr. Chet

Reference: Paxlovid, Vitamin Supplements Show Promise With Long COVID – Medscape – July 29, 2024.

Ice Cream, the Health Food

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Paula gave me an article to read from The Atlantic written last summer, in which author David Merritt Johns tackled the issue of outlandish results in nutrition-science studies. In this case, the issue was research demonstrating that eating ice cream regularly reduced the risk of developing type 2 diabetes and cardiovascular disease. He interviewed the chairman of acclaimed nutrition research schools and departments. He interviewed the scientists who published the results of the studies—or not, in one case, because they wouldn’t talk about it. No one could explain it, it didn’t fit their model, so the results got buried.

I reviewed the studies in question, including the dissertation of the researchers who wouldn’t talk about the study. Any way you look at it, two servings per week of a half cup of high-fat ice cream reduced the risk of the aforementioned conditions between 12–54%. The researchers didn’t want to talk about it or acknowledge it, but the data is the data.

Five Reasons the Data Should Be Accepted

  • The assumption is that the Dietary Guidelines are correct for everyone. Maybe they aren’t.
  • The studies used a food frequency questionnaire. They’ve been used forever and are still no better than they were when developed, like trying to paint the Mona Lisa with a 6-inch brush. For example, how many servings of carrots did you have in July? Few people could answer with any accuracy, so why are we still depending on these tools?
  • They could have assessed the data differently. Divide the subjects by caloric intake first, then by foods or macronutrients. They used the same approach as I’ve talked about before and statistically added a percentage of calories to see how it would impact the results.
  • Maybe the results are just the results. It really confirmed prior studies. Why would you ignore data just because it doesn’t agree with your view of how things should be?
  • Maybe it’s time to stop parsing the imparsible. When the data tell a different story, quit trying to make it fit your theory of nutrition.

Maybe what they should have done is find out what is found in full-fat ice cream but not in high-fat milk or cream, which do contribute to CVD and T2D. Maybe it’s a microbiome issue. Stop saying it’s an outlier and find out why it appears to work.

The Bottom Line

Nobody asked me, but I think it’s portion control. Two half-cup servings per week is very different from two pints a day. That may be the real reason behind the positive results. If you want to have a couple of half-cup servings of ice cream a week, I don’t think it will harm you and just may help. Just pay attention to the portion size.

What are you prepared to do today?

        Dr. Chet

References:
1. http://nrs.harvard.edu/urn-3:HUL.InstRepos:37925665
2. Arch Intern Med. 2005;165:997-1003
3. JAMA. 2002;287(16):2081-2089. doi:10.1001/jama.287.16.2081
4. https://www.theatlantic.com/magazine/archive/2023/05/ice-cream-bad-for-you-health-study/673487/

Questions About Fish Oil

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While I’m spending the day making sure today’s primary election in Michigan goes smoothly in my precinct, here are some of my thoughts and questions about fish oil and omega-3 fatty acids.

  • None of the research to date has focused on complete nutrient intake, and that may have an impact on fish oil utilization. I’ve suggested that before, but vitamins, minerals, and especially phytonutrients from food may have a role to play in how the body uses fish oil and all the fatty acids within it.
  • Speaking of the fatty acids, the omega-3s that are always mentioned are EPA and DHA. In reality, they make up a small part of the fatty acid distribution in fish oil. Could that make a difference? In other words, would the emphasis on those fatty acids impact how omega-3s are used in the body, positively or negatively, compared with straight fish oil?
  • The form of the omega-3 may be important when it comes to bioavailability. There are phospholipids, re-esterified triglyceride (rTG), TG, free fatty acids (FFAs), and ethyl-ester forms of omega-3s. Does the form matter?
  • This is just my opinion, but there’s something in fish that works to improve absorption of omega-3s. Maybe it’s the other fatty acids or maybe it’s the protein in the fish when we eat it. There’s no evidence that oily fish intake increases AFib, so why would the oils alone contribute to any issue unless something is impacting the form mentioned above?

That’s the way I see it. It’s also why I think eating a good diet will prove to be beneficial when taking fish oil. We’ll just have to wait and see.

What are you prepared to do today? If you’re in Michigan, I hope you’re prepared to go vote.

        Dr. Chet

Fish Oil: Reserve Judgment

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Let’s put the fish oil study from Tuesday in perspective. The most important thing is that observational studies such as these cannot demonstrate cause and effect. That’s not just a way to weasel out of making definitive statements; it’s because while fish oil supplements are associated in some way with atrial fibrillation in people who have no diagnosed heart disease, it may be something else that people who take fish oil supplements do that’s actually the culprit. Remember the hazard ratio (HR) was only 13%. What were the remaining 87% doing that was different?

The Problems

As I see it, these were the problems with this research paper.

Just as in the multivitamin study, researchers collected a whole host of dietary data and didn’t use much of it; they adjusted for those who ate oily and un-oily fish, but that was it. Fruit intake, vegetable intake, fiber intake, and a whole lot more dietary factors that have been shown to limit the development of cardiovascular disease were not considered. That may have impacted the HR.

The major problem was that they didn’t report the rate of AFib in those who did not take fish oil supplements. How can you not? What happens to those who do not take fish oil supplements could have provided comparison groups, which seems like a better analysis to conduct. No explanation. They just chose not to do it.

The final critique is that this study was conceived and executed by statisticians and epidemiologists. There were no nutrition experts on the team reported in the paper. I don’t know how that’s possible. If you’re considering a nutritional intervention, such as taking a fish oil supplement, there has to be someone who understands nutrition to consider other factors. It can’t be all statistics without thoughtful guidance.

The Big Question

How? How would fish oil supplements cause the development of AFib?

Research has shown that eating oily fish does not appear to cause AFib. Why would fish oil? The researchers cited a couple of possibilities having to do with an impact on channels that control electrical pathways but overall, no one has given any explanation.

This was not the first study that has examined fish oil supplements in large studies and found some relationship with AFib; there are also several that show no relationship at all. In this case, we have to reserve judgment because we can’t prove things either way.

The Bottom Line

What should you do? First, eat the healthiest diet you can and exercise regularly, because lifestyle is more important than supplements. Second, if you have already been diagnosed with CVD as I have—a stent more than 20 years ago—taking fish oil may be beneficial. If you’re under 60, it seems taking fish oil isn’t an issue and there’s no reason to stop. If you’re older than 60, should you begin to take fish oil supplements? It’s a matter of choice. I have to reserve judgment for now.

Next Tuesday is our primary election day in Michigan, and I’m taking the day off—I’m an election worker—but you’ll still get a Memo that goes into questions on this fish oil issue. There’s more to consider and I’ll let you know what those issues are.

What are you prepared to do today?

        Dr. Chet

Reference: BMJMED 2024;3:e000451.doi:10.1136/ bmjmed-2022-000451

Fish Oil and Atrial Fibrillation

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Researchers recently published an observational study on over 415,000 subjects in the UK Biobank database who took a fish oil supplement. During a follow-up period of almost 12 years, they statistically demonstrated a 13% increased hazard ratio (a measure over time of how often a particular event happens in one group compared to another group) in the development of atrial fibrillation in subjects. Atrial fibrillation is a type of arrhythmia, or abnormal heartbeat, that can result in extremely fast and irregular beats from the upper chambers of the heart. In those subjcts, there was a 5% increased risk of stroke.

The resultant impact was an attack on dietary supplements for being too easily available, leading to overconsumption, and questionable because of the lack of purity in dietary supplements. The Medscape Cardiology online section put out a video by a reputable researcher explaining who should take fish oil supplements. But if they’re so bad, why would she recommend them at all?

The other part of the results showed that if someone already had cardiovascular disease (CVD), the hazard ratio of developing major cardiac events was reduced if they took fish oil supplements. That’s why the expert made the video, taking the good and trying to make sense of it. Still, it gave the appearance of being a pitch for a pharmaceutical solution.

That’s the set-up for this week’s Memos. I’ll give you at least one of the questions you might have: Yes, this study tested only supplement use (and dietary intake) upon entrance to the study and nothing the rest of the 11.9 years, just like the multivitamin study from last week. But there’s so much more that I’ll cover on Saturday about the problems with this study. Just so you know, I’m still taking my fish oil supplements.

What are you prepared to do today?

        Dr. Chet

Reference: BMJMED 2024;3:e000451.doi:10.1136/ bmjmed-2022-000451

Nothing to Fear from the Multivitamin Study

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If you’re concerned about taking your multivitamin, I think you can lower the concern. Is it still possible that there may be individuals who may have a unique set of genes and covariates that may increase the risk? Sure, it’s possible, but this study brought us no closer to finding out if that’s true. Here’s why.

The Issues with the Study

The problems lie in what the researchers didn’t do.

While the researchers used 13 different covariates, they didn’t break the data down by macronutrient or micronutrient. They used the Healthy Eating Index, but that ranks the quality of the diet from 0 to 100; that’s not the same as breaking the subjects’ diets down by intake of vegetables or antioxidants. It’s possible that someone who ate more vegetables could have higher antioxidant levels, which could contribute to getting too much of a nutrient by taking a multivitamin. The same would be true if they also were taking a complete multivitamin-multimineral and getting too much calcium or iron. That might have given valuable information to the people most at risk if there were such a relationship.

The researchers also did not give any explanation for mechanisms through which a multivitamin could increase mortality. That’s not unusual, because they didn’t examine any nutrient factors—but still, what was the point of saying there may be an increase in mortality, but nothing more than that?

The most likely explanation is that the results happened by chance because they tested multivitamin intake only twice early in the studies. Think of what you were eating 20 years ago. Has that changed? It’s reasonable to expect that some peoples’ habits changed, just as their dietary intake may have changed. We don’t know because they couldn’t go back and do the questionnaires every year or two, or even every five years. They suggest that this was a problem due to the latency of the data, and they were correct in my opinion.

The Bottom Line

This study illustrates the problem with going back to analyze data collected decades ago: you’re limited by the data you have rather than actually planning the study from the beginning. It’s an interesting observation after chunking lots of numbers, but it’s not meaningful in the real world due to the lack of ability to do an adequate analysis of the data.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Network Open. 2024;7(6):e2418729.

Will Taking a Multivitamin Increase Your Risk of Death?

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Close to a month ago, the health headlines were full of warnings about multivitamins. A long-time researcher even did a video to explain the study. This headline was based on a study that demonstrated an increase in Hazard Ratio if a person took a multivitamin every day, compared to occasionally or never. On the face of it, this seemed to be a compelling study. Data were combined from three large studies that totaled over 390,000 participants. The data were taken from health and nutrition questionnaires first given more than 20 years ago, with the mean follow up time of about 21 years. The questionnaires asked about a variety of demographic data as well as health and nutrition habits; the nutrition data were the old-style FFQ form.

After analyzing the data, researchers found a 4% increase in mortality risk in those participants who took a multivitamin every day compared to those who did not. Should you be worried? Aside from the number of covariates they considered, and you know how those combinations can add up, there were at least two problems. I’ll cover those on Saturday.

The Winners of the Challenge

Everyone who responded to the 4th of July challenge did an amazing job—no one had fewer than 20 vegetables and fruits. Where it got a little murky was in the herbs and spices; I’ll take the blame for that as I didn’t explain it as well as I should. For the overall total, I’m going to declare a tie between RE and KB; they each had close to 60 foods that qualified! For vegetables alone, VK topped the list with 23 and MW topped the fruit list with 13. Great job, everybody!

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Network Open. 2024;7(6):e2418729.

Nutritional Epidemiology: Still Confusing

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Remember where we began: frustrated with the conflicting studies on nutrition and their impact on our health. The researchers used specification curve analysis to illustrate several issues. The most important point is that there are many ways to analyze large datasets in nutritional epidemiology. Reviewing 15 studies in 24 papers, they found that the number of ways to analyze the data could reach 10 quadrillion (that’s 10,000,000,000,000,000). Obviously, that’s not realistic.

Instead, the approach that could be used by researchers doing these types of studies in any field is to select a randomized sample of different analytical approaches and present the results in the way I did in Tuesday’s Memo. Using that approach showed that fewer than 4% of the studies reached statistical significance. But how much of that could be just dumb luck? Setting the probability of significance at less than .05 (which is most common) means that out of 100 statistical approaches, five could show significance just by chance alone.

This paper addresses a long-standing problem in nutritional research and other areas as well. Researchers who do these types of longitudinal studies already use different analytic techniques in a haphazard way. They just keep chunking data until they find an analytic approach that’s statistically significant, and that’s the one they publish, sort of like a thief checking car doors until he finds one unlocked. Journals won’t publish results that don’t demonstrate significance, even though that would be beneficial for others to find out what not to do. “Publish or perish” just doesn’t work that way.

The Bottom Line

In this series of Memos, I’ve tried to lay out one of the reasons that long-term nutritional studies that look at morbidity and mortality can be flawed, if not contradictory. To be sure, the statistical analyses I’ve talked about are complicated, but that wasn’t my purpose. It’s to let you know that because of the lack of hard and fast rules for outlining the statistical approaches before looking at the data (as is done in randomized controlled trials), the results and the interpretation of those results will always be suspect.

In plain words, never get too excited about longitudinal studies, whether positive or negative. In the coming weeks, I’ll examine some studies on fish oil and multivitamins to illustrate the points I’ve tried to make.

By the way, for those of you really wanting to know whether you should eat red meat based on the analytic study the researchers tested as an example, they stated that there were some holes in the NHANES data that could impact the outcomes they reported. For now, it seems that women may benefit more from eating red meat than men will, but there’s no definitive answer yet.

What are you prepared to do today?

        Dr. Chet

References:
1. https://www.sensible-med.com/p/the-definitive-analysis-of-observational
2. Journal of Clinical Epidemiology 168 (2024) 111278